AGENCY REQUEST FOR INFORMATION FROM THE NEBRASKA
ADULT AND CHILD ABUSE AND NEGLECT REGISTER/REGISTRY
The State of Nebraska approved this form, any alteration will invalidate it.
I hereby request information from the Nebraska Adult and Child Abuse and Neglect Registry. I agree to use the requested information to determine whether to hire or retain the individual to provide care, custody, treatment, transportation or supervision of children or vulnerable adults.
Agency Name/ Fax: Butler County Health Care Center / Fax (402) 367-1385
Please do not use abbreviations
Address and Phone Number: 372 S 9th Street David City, NE 68632 / (402) 367-1372
I hereby authorize the Division of Children and Family Services to disclose whether I have an Adult and/or Child Abuse and Neglect Register/Registry record to the above-named agency.
Print Full Legal Name: (applicant)______
______
Signature (applicant)Date
Current Address: ______
(Street/City/State/Zip)
Applicant Date of Birth Applicant Social Security Number
Other names previously used such as former married names, maiden name and nick names.
Please Print.
Names and birth dates of your children and children who have lived with you. Please Print.
Any Address at which you have resided during the past 20 years. Please Print.
BUTLER COUNTY HEALTH CARE CENTER
372 S. 9TH ST
DAVID CITY, NE 68632
Telephone: (402) 367-1200Contact person: Andra Vandenberg
NOTIFICATION OF PROCUREMENT OF CONSUMER REPORT
Through this document, Butler County Health Care Center (BCHCC) is putting you on notice and disclosing to you that BCHCC may obtain a consumer report, which may include an investigative consumer report, for employment purposes as part of pre-employment background investigation. In addition, such a consumer report, including an investigative consumer report may be obtained at any time during your employment.
An investigative consumer report includes information as to your character, general reputation, personal characteristics and/or mode of living. Information may be obtained through personal interviews with your neighbors, friends or associates to others with whom you are acquainted. Upon your written request received by us within a reasonable time, we will make a complete and accurate disclosure of the nature and scope of the investigative consumer report.
BACKGROUND CHECK AUTHORIZATION
I, the undersigned consumer, do hereby authorize Butler County Health Care Center, by and through its independent contractor, to procure a consumer report and/or investigative consumer report on me.
These above mentioned reports may include, but are not limited to, employment and education verifications; personal references; personal interviews; my personal credit history based on reports from any credit bureau; my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; any other public record; and any other information bearing on my credit standing, credit capacity, credit worthiness, character, general reputation, personal characteristics, trustworthiness and/or mode of living.
I understand that the investigative consumer report I have authorized above may include information obtained by interviews with my neighbors, friends and/or associates and/or others with whom I am acquainted or who may have knowledge concerning said information. I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report prepared on me upon my written request that is made within a reasonable time after the date hereof.
I further authorized any person, business entity or governmental agency who may have information relevant to the above to disclose the same to BCHCC, including, but not limited to, any courthouse, any public agency, any and all law enforcement agencies and any and all credit bureaus, regardless of whether such person, business entity or governmental agency compiled the information itself or received it from other sources.
I understand that this authorization shall remain on file and shall serve as an ongoing authorization for BCHCC to obtain consumer reports, including investigative consumer reports, at any time during my employment, for employment purposes.
SIGNATURE OF APPLICANT/EMPLOYEEDATE
WITNESS SIGNATUREDATE
Helping People Live Better Lives
An Equal Opportunity/Affirmative Action Employer
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